Phenobarbital treatment of alcohol withdrawal in the emergency department: A systematic review and meta‐analysis
Objective Despite frequent treatment of alcohol withdrawal syndrome (AWS) in the emergency department (ED), evidence for phenobarbital (PB) as an ED alternative therapy is mixed. We conducted a systematic review and meta‐analysis comparing safety and efficacy of PB to benzodiazepines (BZDs) for trea...
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Published in | Academic emergency medicine Vol. 31; no. 5; pp. 515 - 524 |
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Main Authors | , , , |
Format | Journal Article |
Language | English |
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01.05.2024
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Abstract | Objective
Despite frequent treatment of alcohol withdrawal syndrome (AWS) in the emergency department (ED), evidence for phenobarbital (PB) as an ED alternative therapy is mixed. We conducted a systematic review and meta‐analysis comparing safety and efficacy of PB to benzodiazepines (BZDs) for treatment of AWS in the ED.
Methods
We searched articles and references published in English in PubMed, Web of Science, and Embase from inception through May 2022. We included randomized trials and cohort studies comparing treatment with PB to BZD controls and excluded studies focused on non‐AWS conditions. Review was conducted by two blinded investigators and a third author; eight of 59 (13.6%) s met inclusion criteria for review and meta‐analysis using a random‐effects model. Treatment superiority was evaluated through utilization, pharmacologic, and clinical outcomes. Primary outcomes for meta‐analysis were the proportion of patients (1) admitted to the intensive care unit (ICU), (2) admitted to the hospital, (3) readmitted to the ED after discharge, and (4) who experienced adverse events.
Results
Eight studies (two randomized controlled trials, six retrospective cohorts) comprised data from 1507 patients in 2012 treatment encounters for AWS. All studies were included in meta‐analysis for adverse events, seven for hospital admission, five for ICU admission, and three for readmission to the ED after discharge. Overall methodological quality was low‐moderate, risk of bias moderate‐high, and statistical heterogeneity moderate. Pooled relative risk of ICU admission for those treated with PB versus BZD was 0.92 (95% confidence interval [CI] 0.54–1.55). Risk for admission to the hospital was 0.98 (95% CI 0.89–1.07) and for any adverse event was 1.1 (95% CI 0.78–1.57); heterogeneity prevented meta‐analysis for ED readmission.
Conclusions
The current literature base does not show that treatment with PB significantly reduces ICU admissions, hospital admissions, ED readmissions, or adverse events in ED patients with AWS compared with BZDs alone. |
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AbstractList | Despite frequent treatment of alcohol withdrawal syndrome (AWS) in the emergency department (ED), evidence for phenobarbital (PB) as an ED alternative therapy is mixed. We conducted a systematic review and meta-analysis comparing safety and efficacy of PB to benzodiazepines (BZDs) for treatment of AWS in the ED.
We searched articles and references published in English in PubMed, Web of Science, and Embase from inception through May 2022. We included randomized trials and cohort studies comparing treatment with PB to BZD controls and excluded studies focused on non-AWS conditions. Review was conducted by two blinded investigators and a third author; eight of 59 (13.6%) abstracts met inclusion criteria for review and meta-analysis using a random-effects model. Treatment superiority was evaluated through utilization, pharmacologic, and clinical outcomes. Primary outcomes for meta-analysis were the proportion of patients (1) admitted to the intensive care unit (ICU), (2) admitted to the hospital, (3) readmitted to the ED after discharge, and (4) who experienced adverse events.
Eight studies (two randomized controlled trials, six retrospective cohorts) comprised data from 1507 patients in 2012 treatment encounters for AWS. All studies were included in meta-analysis for adverse events, seven for hospital admission, five for ICU admission, and three for readmission to the ED after discharge. Overall methodological quality was low-moderate, risk of bias moderate-high, and statistical heterogeneity moderate. Pooled relative risk of ICU admission for those treated with PB versus BZD was 0.92 (95% confidence interval [CI] 0.54-1.55). Risk for admission to the hospital was 0.98 (95% CI 0.89-1.07) and for any adverse event was 1.1 (95% CI 0.78-1.57); heterogeneity prevented meta-analysis for ED readmission.
The current literature base does not show that treatment with PB significantly reduces ICU admissions, hospital admissions, ED readmissions, or adverse events in ED patients with AWS compared with BZDs alone. OBJECTIVEDespite frequent treatment of alcohol withdrawal syndrome (AWS) in the emergency department (ED), evidence for phenobarbital (PB) as an ED alternative therapy is mixed. We conducted a systematic review and meta-analysis comparing safety and efficacy of PB to benzodiazepines (BZDs) for treatment of AWS in the ED.METHODSWe searched articles and references published in English in PubMed, Web of Science, and Embase from inception through May 2022. We included randomized trials and cohort studies comparing treatment with PB to BZD controls and excluded studies focused on non-AWS conditions. Review was conducted by two blinded investigators and a third author; eight of 59 (13.6%) abstracts met inclusion criteria for review and meta-analysis using a random-effects model. Treatment superiority was evaluated through utilization, pharmacologic, and clinical outcomes. Primary outcomes for meta-analysis were the proportion of patients (1) admitted to the intensive care unit (ICU), (2) admitted to the hospital, (3) readmitted to the ED after discharge, and (4) who experienced adverse events.RESULTSEight studies (two randomized controlled trials, six retrospective cohorts) comprised data from 1507 patients in 2012 treatment encounters for AWS. All studies were included in meta-analysis for adverse events, seven for hospital admission, five for ICU admission, and three for readmission to the ED after discharge. Overall methodological quality was low-moderate, risk of bias moderate-high, and statistical heterogeneity moderate. Pooled relative risk of ICU admission for those treated with PB versus BZD was 0.92 (95% confidence interval [CI] 0.54-1.55). Risk for admission to the hospital was 0.98 (95% CI 0.89-1.07) and for any adverse event was 1.1 (95% CI 0.78-1.57); heterogeneity prevented meta-analysis for ED readmission.CONCLUSIONSThe current literature base does not show that treatment with PB significantly reduces ICU admissions, hospital admissions, ED readmissions, or adverse events in ED patients with AWS compared with BZDs alone. Objective Despite frequent treatment of alcohol withdrawal syndrome (AWS) in the emergency department (ED), evidence for phenobarbital (PB) as an ED alternative therapy is mixed. We conducted a systematic review and meta‐analysis comparing safety and efficacy of PB to benzodiazepines (BZDs) for treatment of AWS in the ED. Methods We searched articles and references published in English in PubMed, Web of Science, and Embase from inception through May 2022. We included randomized trials and cohort studies comparing treatment with PB to BZD controls and excluded studies focused on non‐AWS conditions. Review was conducted by two blinded investigators and a third author; eight of 59 (13.6%) s met inclusion criteria for review and meta‐analysis using a random‐effects model. Treatment superiority was evaluated through utilization, pharmacologic, and clinical outcomes. Primary outcomes for meta‐analysis were the proportion of patients (1) admitted to the intensive care unit (ICU), (2) admitted to the hospital, (3) readmitted to the ED after discharge, and (4) who experienced adverse events. Results Eight studies (two randomized controlled trials, six retrospective cohorts) comprised data from 1507 patients in 2012 treatment encounters for AWS. All studies were included in meta‐analysis for adverse events, seven for hospital admission, five for ICU admission, and three for readmission to the ED after discharge. Overall methodological quality was low‐moderate, risk of bias moderate‐high, and statistical heterogeneity moderate. Pooled relative risk of ICU admission for those treated with PB versus BZD was 0.92 (95% confidence interval [CI] 0.54–1.55). Risk for admission to the hospital was 0.98 (95% CI 0.89–1.07) and for any adverse event was 1.1 (95% CI 0.78–1.57); heterogeneity prevented meta‐analysis for ED readmission. Conclusions The current literature base does not show that treatment with PB significantly reduces ICU admissions, hospital admissions, ED readmissions, or adverse events in ED patients with AWS compared with BZDs alone. |
Author | Lee, Carmen M. Dillon, David G. Tahir, Peggy M. Murphy, Charles E. |
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Cites_doi | 10.1001/jamanetworkopen.2021.0422 10.1177/1536867X0800800102 10.1016/j.alcohol.2019.07.004 10.1136/bmjopen-2023-073232 10.1111/acer.13559 10.1016/j.ajem.2019.01.053 10.2147/OAEM.S235288 10.1186/s12916-022-02369-2 10.1093/alcalc/agw074 10.1016/j.jemermed.2012.07.056 10.1001/jamanetworkopen.2020.22942 10.1097/01.CCN.0000578828.37034.c2 10.1186/s12873-021-00524-1 10.1001/jama.2022.4308 10.1007/s13181-021-00863-2 10.1111/add.15589 10.1016/j.jclinepi.2019.10.013 10.1016/j.ajem.2022.02.020 10.1016/j.ajem.2009.10.010 10.1016/j.ajem.2019.01.002 10.4037/ajcc2018745 10.1002/sim.1186 10.1186/s12874-016-0136-0 |
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Notes | Funding information Dr. Dillon was supported by the grant R38HL143581 from the National Heart, Lung, and Blood Institute. Presented at the American College of Emergency Physicians’ Scientific Assembly, San Francisco, CA, October 2022. Richard Sinert Supervising Editor ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-3 content type line 23 ObjectType-Review-2 ObjectType-Undefined-4 |
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References | 2021; 21 2023; 13 2021; 4 2013; 44 2020; 82 2021; 28 2019; 37 2019; 14 2020; 38 2008; 8 2020; 12 2022; 20 2018; 42 2018; 27 2017; 52 2020; 3 2022 2021; 116 2002; 21 2020; 118 2022; 54 2022; 327 2011; 29 2022; 18 2016; 22 e_1_2_7_6_1 e_1_2_7_5_1 e_1_2_7_4_1 e_1_2_7_3_1 e_1_2_7_9_1 e_1_2_7_8_1 Henson P (e_1_2_7_26_1) 2021; 28 e_1_2_7_7_1 e_1_2_7_19_1 Sullivan SM (e_1_2_7_29_1) 2019; 37 e_1_2_7_16_1 e_1_2_7_2_1 e_1_2_7_15_1 e_1_2_7_14_1 e_1_2_7_13_1 e_1_2_7_12_1 e_1_2_7_11_1 e_1_2_7_27_1 Higgins JPT (e_1_2_7_17_1) 2022 e_1_2_7_28_1 Wolf C (e_1_2_7_10_1) 2020; 12 e_1_2_7_30_1 e_1_2_7_25_1 e_1_2_7_24_1 e_1_2_7_23_1 e_1_2_7_22_1 e_1_2_7_21_1 e_1_2_7_20_1 Sterne JAC (e_1_2_7_18_1) 2022 |
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Despite frequent treatment of alcohol withdrawal syndrome (AWS) in the emergency department (ED), evidence for phenobarbital (PB) as an ED... Despite frequent treatment of alcohol withdrawal syndrome (AWS) in the emergency department (ED), evidence for phenobarbital (PB) as an ED alternative therapy... ObjectiveDespite frequent treatment of alcohol withdrawal syndrome (AWS) in the emergency department (ED), evidence for phenobarbital (PB) as an ED alternative... OBJECTIVEDespite frequent treatment of alcohol withdrawal syndrome (AWS) in the emergency department (ED), evidence for phenobarbital (PB) as an ED alternative... |
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SubjectTerms | Alcohol withdrawal Benzodiazepines - therapeutic use Emergency medical care Emergency Service, Hospital Humans Hypnotics and Sedatives - therapeutic use Phenobarbital - therapeutic use Substance abuse treatment Substance Withdrawal Syndrome - drug therapy Systematic review |
Title | Phenobarbital treatment of alcohol withdrawal in the emergency department: A systematic review and meta‐analysis |
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